Depression Update

Twyla and I started our depression project in October 2012.  As of March 1, 2013, 60 patients had at least 2 PHQ9 scores and at least one PHQ9 score diagnosing them with depression.  Twenty three of those 60 (38%) had at least a 40% improvement in their scores.  We are identifying them, helping them access treatment, medical, therapy or both, and improving their care.  I like the model so far.

Weight Loss Strategies

I think I can lose weight.

Right now, I'm heavy, ok, I'm obese.  No really, my BMI is 34.8.  I tried two different online calculators and they gave me the same result.

I wasn't always obese.  In HS I wrestled and played football.  I loved sports and played pickup games all year.  I tore my right knee up twice in college and had to stop playing basketball at age 29.  I never did exercise regularly again.  I also never changed my eating habits.  The serving sizes and choices from HS followed me for a long time.  2005 was a stressful year and I grew from 200 pounds to 220.  By last year I was up to 230 and I'm only 5' 6"!

But I've got a plan.  It might help you, it might not.  But I've got a plan.

I'm a numbers nerd.  If I can measure it, I can manage it.  If I can't measure it, I'm in trouble.  Five or 6 years ago, I lost 25 pounds in about 3 months by counting calories online.  I used about.com's calorie count plus.  After a while, entering the foods became tiresome and I stopped.  I looked at livestrong back then and the app wasn't very good.  And like I mentioned, by last year I was up to 230, at home, after drying the shower water off.

I went to see my doctor recently and he told me I weighed too much.  He was very tactful and didn't call me obese.  He told me his doctor instructed him to count calories and that he found an easy tool called My Fitness Pal.  I shared my previous experience and agreed to try it.

So I'm early in the game.  It's definitely easier to use and get graphs (numbers nerds like graphs).  It also has a built in peer support piece.  You can invite friends or others who are trying to lose weight.  MyFitnessPal will send them a message if you've lost weight, logged in or fallen off the horse.  I started on Saturday March 2, 2013 at 224 pounds and after 2 weeks I was down to 215.4.  My BMI has come down from 36.2 to 34.8.  I like the pace and more importantly, I like the feedback from my food choices..

Every time I enter something I ate, I get immediate feedback.  If it tastes good and has low calories, I eat it again.  If it brings too many calories, I eat it less.  If it tastes bad, I don't eat it again.  Ever.   Most importantly, I eat delicious non-diet food.

Below are some of the lessons I've learned.

• Grapes have a lot of calories.  I love grapes.  My wife packs small zip log bags of them as part of my lunch. Two cups of grapes is 208 calories.  No wonder she called them nature's candy.  
• Epicurious.com is awesome.  Sure, I walk through the vegetable isles but I don't see yummy, I see boring.  You must experiment.  Do not just eat steamed or saute'd vegetables.  You will grow tired of them.  With epicurious, I buy what's in the receipe, cook it and get yummy.  I get asian yummy, mediterranean yummy, southwest tex-mex yummy, african yummy and this is just the vegetables. 
• Yummy is important because vegetables are the key to losing weight.  They fill you up, you really feel full and they have super, super low calories and many have super low carbs.
• I eat a lot of meat.  I'm a carnivore which is good as it's low-calorie, low-carb food and takes a while to digest.  Just don't eat too much sausage.  Very high calories.  If you know what scrapple is, well, I warned you.
• I have a low fat diet when I avoid soft flour tortillas.  It is true, they are carbohydrates but, I almost always melt shredded cheese on them.  I'm not eating the tortillas and my fat intake is very low.  Sometimes I think I should replace some of my carbohydrates with fat.  We'll see.
• I eat too many carbs.  I agree with South Beach.  Carbs make me hungry.  And I eat too many carbs.  But carbs are so easy.  They don't go bad.  They come in cute little plastic packages.  You can find them anywhere.  Try walking into 7-Eleven to grab a nice piece of salmon.  Still, I eat too many carbs.  Gotta figure that one out.
• Don't drink so many calories.  Drink water for thirst, drink other stuff for other reasons.  I don't drink black coffee and I need coffee.  Red wine is nice too.  Gatorade only if you were sweating!  I'm glad I don't drink much beer anymore.  Twenty percent of all beer drinkers drink 80% of all the beer.  Beer drinkers are only thin on TV.
• Don't watch TV.  Really, just don't do it unless there's a game on or your watching a second season marathon of A Game of Thrones.  TV commercials are evil.  They are pavlovian.  Repeat, don't watch TV.
• If you get a sandwich at Panera or Subway or somewhere else, eat the first half and stop.  Unless you're Andre the giant, you're full.  Wrap it up and eat it later, even only 20 minutes later.  Just don't eat it all or you'll reach that sub-bursting feeling.  If you feel like you're going to burst, you're gaining weight.
• Cook a lot on Sunday.  Cook a couple different things, then mix and match them for lunch and dinner during the week.  I work hard.  I'm not cooking yummy from scratch on Tuesday night.  Not happening.  I'm re-heating or getting take out.  
• Don't eat take out.  Unless it's a turkey sandwich or sushi.

Cook yummy, eat yummy, count the calories, watch what I drink and no take out.  

Man it's been a long time.  Life gets that way I guess.

I wanted to share a little process we're working on.

We all know that roughly 25% of the patients who visit a primary care office in any given year are depressed at one of their visits.  I work in a Federally Qualified Health Center (FQHC) serving mostly the un- and under-insured and our rates are probably higher than that.  

We also know that depression is vastly under-diagnosed in primary care.  There's a PHQ-2 screening tool for depression and then a PHQ-9 diagnosis and monitoring tool for depression.  Basically, if either of the first two questions are positive, you ask the next seven questions.  If the PHQ-2 is positive, you just added 9-10 minutes to the visit.  Those of us who admit it will tell you that adding 9-10 minutes to a 15-20 minute prohibits using the PHQ2.

Then my medical assistant Twyla Womack took over.  At first, she gave the PHQ-9 form to the patients and asked them to fill it out while they wait for me.  Who cares if they fill out all 9 questions when the first 2 are negative?  She would then leave the form for me to see when I went into the room.  Later, she would enter the results into the EMR.  She easily saved me 8 minutes for every positive PHQ-9.  After a while, she noticed that some patients skipped some of the questions and so she wasn't sure people fully understood the questions.  At that point, she started asking the questions and recording the patients' answers directly into the EMR.

From October 1, 2012 through January 31, 2013, even though I was only seeing patients 16 hours per week, Twyla completed and documented 240 PHQ-9s in our EMR, plus all the negative PHQ-2s!  

We need to crunch more data to see the longitudinal change in PHQ-9 scores to make sure we're having a clinical effect.  However, you can only treat what you can diagnose.